University, City, Community

 

Can it be over 33 years ago that this fresh-faced 18-year-old kid from the San Francisco Bay Area suburbs first arrived in Philadelphia? I had been to this city and to the Penn campus exactly one time in my life prior to that, and I was a teenager with hardly any worldly experience, so whatever initial expectations and first impressions I might have had were shallow at best. Nevertheless, I'm sure that what first drew me to the place (besides the world-class education available at Wharton) and what excited me upon actual arrival was an urban form that seemed to click for me. Coming from a car-dominant part of the country, being able to navigate solely via walking, biking, and transit created a literal sense of movement, energy, and interaction that worked for me. Not that 18-year-old me could've afforded a car or wanted to bear the headache of insuring, parking, and maintaining it. But still, it was liberating to be plopped into a brand new place and be able to get around without being tethered to a large and expensive machine.

It turns out that kind of circulation is good for all sorts of things that I subsequently came to value and understand. Tolerance is bred when we interact with people different from us rather than being sequestered inside our climate-controlled vehicles. Cultural exchange and crossover exposure begets the sort of explosion of ideas, expression, and production that makes people happy and places thrive. And the innovation that drives a region's competitiveness occurs in the very places where lots of smart people can easily work, play, and dream together, planned and unplanned.

Fast forward to the present, and the prospects for the Philadelphia region are bright in relation to the activity taking place in this little sliver of the region that I now call home. University City is home not only to world-class universities and hospitals, but also to a whole constellation of research institutes, startup ventures, and dominant science industry players. With this massive physical footprint of innovation infrastructure and industry activity, the center of gravity for the region has grown from what we in the region call "Center City" (i.e. our downtown) to a "Greater Center City" that jumps across the Schuylkill River to include most of my University City neighborhood (and I believe, one day, will also jump across the Delaware River to include parts of Camden, New Jersey). The future holds much in venture capital raised, businesses birthed, and scientific discoveries brought to market. 

All of this is happening in a physical place that cannot be detached from other things happening in the same space: households of all income levels, K-12 schools, and a rich mix of small non-profits. Which is good: you don't want a sterile, mall-like setting for pushing scientific boundaries and conducting life-changing research. But it does reinforce a central premise that most of us desperately want but few of us know how to achieve, which is: how do you make sure that a soaring tide truly lifts all boats and doesn't swamp the most vulnerable?

Much easier said than done, to be sure. But think of where equity can meet opportunity:

* All this activity is only as good as a steady stream of talent at all educational levels, so we must invest in thoughtful collaboration that connects people looking to build their careers with employers seeking labor. The best way to lift up our lower-income households is through gainful employment, and we just so happen to be sitting on some of the highest-growth sectors and companies right in our own backyard. Making the connection is benefitted by proximity, but it does not happen without intention, via skill-building and laddering and exposure and supports.

* More activity and more people usually means more demand for housing, which absent new supply means (by the law of economics) price goes up. Which is exactly what people worry about when they talk about gentrification and displacement. Alas, artificial attempts to control price, or expensive ways of adding supply, are prohibitive, yielding solutions that are ineffective or impractical. Better to push in other places, namely making it easier to add supply anywhere and everywhere, incentivizing existing landlords to maintain their units in good condition, and creating opportunities for people to make more money (and therefore afford higher rents). More supply means more and better choices for all, with the the positive consequences for the households with the fewest resources.

* The power of agglomeration only comes into play if adding more gets you even more, exponentially even, as in 1 plus 1 becomes 2 and then 1 more becomes 3 or more and then 1 more becomes 4 or even more. Alas, in many cases adding more has diminishing or even negative returns, where 1 plus 1 is 2 but 1 more becomes less than 3 and then 1 more starts to become even less. Namely, traffic and congestion rear their ugly head, yielding inefficiencies and headaches such that people eventually make choices to go elsewhere. Which is why investment in transit - routes, frequency of service, and the rider experience - is so important. Because that is what allows places to scale, is that they are not predicated on more people driving more cars into the same area. Owning a car is so expensive compared to walking, biking, and transit, so places that require driving are impenetrable for poorer households, and conversely places that are more multi-modal unlock opportunities for those same households.

* People are not robots. They love beauty, hate blight, and avoid dangerous places like the plague. A safe street, a vibrant commercial corridor, and a pleasant pocket park are truly public goods, which can be freely enjoyed by all without barrier (what economists call "non-excludable") and which can largely be enjoyed by more and more without diminishing or crowding out the experience of others (what economists call "non-rivalrous"). Indeed, in such settings, the more people that enjoy something, the better the experience is, for who doesn't prefer people-watching in an active public space over walking through an abandoned public space? Given this leveling, less resourced households gain the most when public spaces are secured and made more beautiful.

The future of University City, of Philadelphia, and of cities in general is up in the air. Who knows what tomorrow will bring? All I can hope for is more progress like what we've seen since I arrived 33 years ago, and more of what I've listed above to make sure that happens and does so in ways that are equitable.

Of the People

 

 

Income inequality is a hot topic these days, as we lament the growing gap between the have's and have-not's and consider what we can do at a local and national level to address this. To be sure, who we elect as President and what policies we push for in City Hall matter greatly, and we rightly focus our finite attention to advocacy there. But it seems a matter of personal integrity that our own life decisions line up with what we say we want societally.  

The thing about a society, at least a free and democratic one like the one we're lucky to have in this country, is that it is a messy compilation of individuals and households that have their own personal preferences as well as broader desires for the overall community they live in. I respect that, within reason, whatever someone wants to do, even if different from me, they are free to do. Indeed, that freedom and those differences are a critical aspect of what makes America special. So I do not begrudge any decision that someone makes for their own good, so long as it does not adversely affect me or others in a material way.

Yet, the accumulation of individual decisions does in fact sometimes result in systemic inequality. In fact, that is exactly how inequity works: it is a system that is bigger than all of us, and yet it is also a system that all of us are contributing to and influenced by. Systemic injustice may be a structural thing, for which we must take collective action. But it is also the sum of personal choices you and I make on a daily basis.

Let me give you an example. More resourced families, by definition, have more choices. If they all choose to live in one place and send their kids to schools in that place, that place will be well-resourced. Which is what most well-resourced families want. But that concentration of resources can come at the expense of those with fewer resources and options having less.

(You may argue, just to continue in this specific analogy, that that is why an important function of government is redistribution: tax the rich to provide services for the poor. But to me this feels inadequate, for it's more than just taking the well-off place's taxes to pay for nicer schools elsewhere. If rich kids only go to school with other rich kids, and poor kids only with other poor kids, didn't we have some pretty serious Supreme Court action condemning that as wrong?)

As a well-off person, I struggle with this on a number of dimensions, namely philosophically and what I personally want and what I want for my kids. I am as concerned as the next person that there is such a difference and divide in our country. But if I'm being honest, I personally enjoy the opportunities I am lucky to have, not just to enjoy nice things but to make intentional decisions that set myself apart from others:

* I take my kids to an outdoor pool club that only paying members have access to

* I enjoy the comfort and convenience of solo driving to the supermarket for groceries when others have to endure long bus rides and carry heavy bags

* I'm sure that when I take the kids to Disney next, I will pony up the extra dough to cut in front of others who have to wait in line

I do not feel guilty about doing these things, as I am entitled to spend my hard-earned money in ways that are practical and enjoyable. But they represent a tangible way I lean into my privileges and distance myself from others less fortunate, rather than forgo them or fight to level the opportunities so all can access them.

On a positive note, we have made major life choices so that are kids are exposed to a diversity of people and life circumstances. Where we live, where they go to school, and generally where we hang out are things we can control, and based on what we've decided to do as a family, we are fortunate to be exposed to a wonderful mix of walks of life. 

I am grateful that our kids' formative years are being shaped by this kind of diversity, which I hope builds in them open-mindedness and empathy and humility. I'm sure they too will contend with the same inner wrestlings as I have, to care about equity in our society, to want to work for it "out there," and to also know that part of working for it means having integrity in our own personal life choices.

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Here are a few excerpts from a book I recently read, "The Alchemist," by Paolo Coelho.

 

"I'm going to wait here for you every day. I have crossed the desert in search of a treasure that is somewhere near the Pyramids, and for me, the war seemed a curse. But now it's a blessing, because it brought me to you."

"I have been waiting for you here at this oasis for a long time. I have forgotten about my past, about my traditions, and the way in which men of the desert expect women to behave. Ever since I was a child, I have dreamed that the desert would bring me a wonderful present. Now, my present has arrived, and it is you."

"Why don't people's hearts tell them to continue to follow their dreams?" the boy asked the alchemist.

"Because that's what makes a heart suffer most, and hearts don't like to suffer."

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Here is an excerpt from a book I recently read, "Let Us Descend," by Jesmyn Ward.

 

 "They brand you," Esther told me. "They brand you with the fleur-de-lis on your face," she said, "so everybody, every person who sees you, knows you done fled and got caught. They put chains on your feet, make you walk with stell bracelets 'til they grow into your skin. They put collars on you, metal collars that eat your neck, make little necklaces of sores. And that's if they don't shoot you, if they don't hang you, if they don't slit your throat because you had the gall to take yourself back." 

Unpopular

 

One of the things I remember when I first learned about Myers-Briggs personality types in college is that my type (INTJ) is comfortable with and in fact seeks out unpopular opinions, not necessarily to hold them but to test them in order to learn more and push the envelope. I recall thinking that that characterized me, and I also recall thinking that this insight also meant such impulses did not come as easily to others.

Fast forward to the present, and I still think about this, particularly as we have become a more outwardly divisive and antagonistic culture. I respect the fact that voicing unpopular opinions is sometimes not a matter of stimulating intellectual discourse but something that is hurtful, inflammatory, and destructive. And I respect the fact that power dynamics are such that some are able to bear hypotheticals more freely whereas for others mere suggestions exacerbate existing vulnerabilities. One must tread lightly when probing things that have the potential to cause harm and unravel tenuous calm.

But one must still tread. For each of us to be informed, we must keep an open mind, even and perhaps especially to things we reflexively oppose. And for all of us to be informed, the media must do its job objectively and doggedly, seeking truth even if it yields inconvenient conclusions or is being guarded by the powerful.

Of course, this is simultaneously most important and most difficult for our most contentious issues. Climate change and infectious pandemics are incredibly complex things to get a handle on, so we must keep an open mind in order to properly learn and act, and yet we so easily default to name-calling instead. Similarly, it is critically important to hold our leaders to account, yet too much media coverage feels like the press either has it out for someone or is giving them a pass, leaving the rest of us to make sense of the biased coverage, under-coverage, or even utter lack of coverage.

I realize that this comes more easily for us INTJs, but I still think this is something we all need to work on. Let's be more empathetic that when considering every angle and seeking out the truth, we do not offend and we do not harm. But let's be less concerned that when considering every angle and seeking out the truth takes us in the direction of something that is unpopular, we will care more about getting it right than about how we are perceived.

BS Detector

 

I'm old enough to remember the world before social media AND cable news. Outlets were few - one major newspaper per region, a few local news stations, and the Rather/Brokaw/Jennings triumvirate at the national level. These sources were universally consumed and generally trusted, even as we've now grown to realize they like everyone had their biases. One thing in their favor is that their relative monopolies, combined with the slower cycle by which information churned, meant that the default process was to verify everything before saying anything.

Fast forward to the present and it's a free for all. Cable news and now social media is a race for eyeballs, clicks, and engagement, which seems to bear little incentive with factual reporting and balanced perspectives and instead seems to have bred a predisposition for premature speculation and blatant sensationalism. 

But, go back to my first paragraph, and to a throwaway clause I put in there about everyone having a bias. The point I'm making is all information is potentially tainted. I certainly prefer substance and verification over sugary fluff and unconfirmed conjuncture. But, I also don't want to unnecessarily confer sainthood to our "good ol' days." There's something to be said about lots of information fast, practically in real time, when compared to "I have to wait a day and even then I only get one viewpoint."

"More is better" and "faster is better" depends, though, on having a strong BS detector. I think I'm better off consuming information from a wide range of sources in a wide range of platforms, than if I rely solely on one source - a single newspaper or social media influencer - but only because I'm willing and able to wade through the noise, the falsehoods, and the half-truths while processing information on a topic. 

Indeed, the noise, falsehoods, and half-truths are part of the information one needs to consume in order to understand a topic. Not that you believe those things or put any stock in them. Rather, you realize they must exist for a reason, and it's useful to consider what that reason is when trying to get your arms around a hot topic.

I sure hope the best for the future of journalism, that it is committed to detailed reporting, good storytelling, and calling out bias. But I know there will also be lots of bad journalism, pseudo-journalism, and "hot takes" that don't even attempt to be journalism. All of that is part of the landscape we must process in order to understand what's going on out there. How's your BS detector at processing all that?

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Here are a few excerpts from a book I recently read, "Empire of the Scalpel: The History of Surgery," by Ira Rutkow.

What is significant is the Hippocratic-based conviction that health and illness can be explained through an understanding of nature, apart from the shackles of religion and speculation. Pre-Hippocratic Greek healers regarded disease as being of supernatural origin, caused by angry gods or demonic possession. The underlying concepts in the Corpus opposed these beliefs. There is not a single mention of evil spirits in the entirety of the writings. Instead, what the Corpus offered was a biologic-based approach to disease. 

The followers of Hippocratic-style medicine believed that ill health was not a punishment brought by angry gods but the consequence of lifestyle choices, environmental issues, and other mitigating factors including mind-set and social class. They called for an analytic approach to healing, one independent of dogmatism and hearsay and, instead, based on inspection and observation.

The original Oath set Medicine’s moral high ground. At the same time, it sowed confusion, as its prohibitions against performing an abortion and assisting a suicide conflicted with the fact that some Hippocratics engaged in those activities. This ambivalence broadened when it came to the practice of surgery. The original Oath specifically forbade cutting: “I will not use the knife; not even on sufferers from stone, but will withdraw in favor of such men as are engaged in this work.”

The proscription established an unmistakable division between Hippocratic-influenced physicians and the class of individuals who performed surgical operations. Like that of their Babylonian predecessors, who consigned surgery to a lesser standing within Medicine, the Greeks left the craft and its work of the hand to itinerant craftsmen and roustabouts. This clear-cut separation is reflected in the etymological derivation of the words “surgery” and “medicine.” “Surgery” originated from the ancient Greek cheiros (hand) and ergon (work) and was then modified into the Latin chirurgia, which led to the French chirurgien and finally the English “surgerie.” In contrast, “medicine” is derived from the Latin medicus, meaning “a learned physician.”

Despite surgery’s imperfect knowledge and hard-nosed amputation/extirpation approach to disease, much like a broken clock that shows the correct time twice a day, surgeons occasionally cured, always with brutal self-confidence. What surgery needed for its further advancement was the elucidation of four basic but crucial clinical fundamentals: 1) an understanding of human anatomy; 2) the ability to control bleeding; 3) minimizing the risk of infection; and 4) reducing pain. Taken together, these four issues were more critical than advancing the mechanics involved in a surgical operation. Without these foundational elements, mere technical improvements in surgical technique were doomed to failure. And, like Alexandre Dumas’s musketeers’ creed, “All for one and one for all, united we stand, divided we fall,” the four fundamentals had to work in concert for an operation to succeed. None could stand alone.

For doctors-to-be, their first encounter with a cadaver (I had never seen a dead body before) can be a time of high anxiety. After all, to willfully take apart a human body is far from normal. From the psychological concerns that accompany the dismemberment of a human being to the distinctive odor of the chemicals that preserve cadavers—fruity and foul, somewhere between spoiled juice and stale urine (vestiges of the smell are imprisoned in my olfactory nerves)—medical students routinely name their cadavers as a way to deflect the strangeness of the situation. In Walter’s case, a nickname was not necessary. A paper tag that provided his identity and told of his medical woes had been inadvertently left dangling from one of his toes. Walter was his real name and his life must not have been pleasant. He suffered from alcoholism, cirrhosis, emphysema, and heart disease and had died eight months earlier in one of Missouri’s old soldiers’ homes.

Up to the time of Cheselden, lithotomy was a gruesome procedure and sufferers from bladder stones only submitted to it when the agony of their condition made life insufferable.II The ghastly operation involved a deep and lengthy incision in the perineum (the area between the anus and scrotum or vulva), the passage of a metal rod through the penis or vagina into the bladder to serve as a guide, and the extraction of the stone with a forceps inserted through the incision and pushed into the bladder. The whole process often took more than an hour, and without anesthesia, plus the always-looming problem of infection, it was a horrific ordeal. 

Through extensive research on the anatomy of the perineum and lower abdomen, Cheselden revised the placement of incisions for lithotomy such that blood vessels, intestines, and the prostate were less likely to be injured. Utilizing these modifications, Cheselden was able to complete the operation in one to two minutes, compared with one to two hours, and reduced the complication rate from over 50 percent to under 10 percent. Cheselden’s almost sleight-of-hand operative dexterity was astonishing and his ability to nimbly deliver a bladder stone within seconds of making an incision brought him worldwide acclaim.

Hunter’s belief that gonorrhea and syphilis were caused by the same agent or toxin was based on the long-established attitude that two diseases could not exist in an individual at the same time. Hunter knew that the clap and pox had different symptoms and thought gonorrhea represented the local expression of the disease while syphilis emerged once the illness spread throughout the body. Since the ever-curious Hunter could rarely resist the challenge of studying an ailment ripe for scrutiny, he determined to inoculate a person with gonorrhea and monitor him for the onset of syphilis. If, as Hunter postulated, symptoms of gonorrhea were followed by symptoms of syphilis, then the two diseases were one and the same. Contrariwise, if no suggestion of syphilis emerged, then they were separate entities. What he needed was an individual willing to be infected and a donor with severe enough gonorrhea to provide the sickening pus. 

Not surprisingly, the search to find a suitable volunteer proved fruitless. Hunter then made an expeditious and pragmatic decision: he would serve as the experimentee. Hence, in the spring of 1767, Hunter smeared a lancet with gonorrheal pus from one of his patients and inoculated himself by puncturing the foreskin and head of his penis. Within days, a gonorrhea-like discharge oozed from Hunter’s urethra. Two weeks later, a syphilitic chancre appeared on his prepuce. Hunter was ecstatic. As far as he was concerned, the experiment was decisive; the two illnesses were one, merely appearing in different states in the human body. “[The research] proves that matter from a gonorrhea will produce chancres,” wrote Hunter, “and opens fields for further conjectures.”8 There was one major flaw—Hunter’s findings were erroneous. He did not know that the anonymous penis he used as a source of gonorrhea also harbored syphilis. Hunter had unintentionally infected himself with both diseases.

Most professions have a watershed moment, a time after which things will never be the same. For surgery, its turning point began in 1846 with the discovery of anesthesia and ended in 1867 with the development of antisepsis. The availability of anesthesia and antisepsis to control pain and infection—the last of four crucial fundamentals essential for the performance of effective and safe surgical operations (the first an understanding of anatomy and the second the capability of controlling bleeding)—dramatically transformed the experience of patients. Yet the introduction of these two epochal innovations was contentious, marked by profound debates concerning life, death, suffering, and the very nature of human existence.